Prenatal Syphilis Screen Cuts Stillbirths

Action Points

Note that more than two million pregnant women have active syphilis every year which can result in adverse outcomes such as late abortion or stillbirth, prematurity, or neonatal death, as well as congenital syphilis.

Point out that this review of the literature indicates that interventions to improve the coverage and effect of screening programs for antenatal syphilis could reduce stillbirth and perinatal death by 50%.

Screening pregnant women for syphilis could reduce by more than half the persistent toll of the disease in stillbirths and perinatal deaths, a meta-analysis suggested.

Pooled estimates of four studies found a decrease of 54% (95% CI 18% to 74%) in perinatal deaths in clinics using antenatal screening interventions to identify women infected with syphilis, according to Sarah Hawkes, PhD, of University College London, and colleagues.

Moreover, pooled estimates from three studies showed a reduction of 58% (95% CI 7% to 81%) in the incidence of stillbirth when screening interventions were in place, the researchers reported online in The Lancet Infectious Diseases.

Each year, more than two million pregnant women worldwide have active syphilis, and unless they undergo screening and treatment, more than two-thirds have adverse outcomes including late abortion or stillbirth, prematurity, or neonatal death, as well as congenital syphilis.

And although most countries recommend antenatal screening for syphilis, adherence to these policies is low.

To assess the components and efficacy of interventions that increase screening and improve outcomes, Hawkes and colleagues performed a systematic review and meta-analysis that included 10 studies and more than 41,000 women.

In studies that took place in low- and middle-income countries, all evaluated the use of at least one decentralized intervention, such as point-of-care testing.

Most utilized a rapid-plasma-reagin test, almost all emphasized same-day treatment, and six of the 10 studies encouraged partner notification.

Nine studies looked at at least one aspect of improving the health system, such as through training and provision of laboratory support.

Only one study reported the effect of an intervention on the percentage of women who had their first antenatal visit before four months of gestation, the authors noted. In that study, the intervention was associated with an increase in first-trimester testing from 9.4% to 42.5%.

Three studies included information about third-trimester screening for syphilis. In one of these, among women who had been screened and been found positive for syphilis in early pregnancy, 41% were negative at the time of delivery, compared with 24% of women in a control group.

Treatment regimens varied among the studies, but in general, women in the intervention group were more likely to receive at least one dose of penicillin than were controls.

In one of the three studies that looked at partner notification and treatment, more than three-quarters of the partners were treated, compared with almost none of controls' partners.

However, little information was available on the outcomes of partner treatment or on possible adverse effects on the women, such as through partner violence relating to the infection.

Four studies reported on the incidence of congenital syphilis, and although the results were too heterogeneous to quantify in meta-analysis (I2=075.1%), the rate was consistently lower in the intervention group.

The risk ratios for perinatal death and stillbirth in the intervention group were 0.46 (95% CI 0.26 to 0.82) and 0.42 (95% CI 0.19 to 0.93), respectively.

The authors asserted that their study demonstrated that screening pregnant women for syphilis could decrease adverse pregnancy outcomes, but they acknowledged that barriers remain.

Of particular importance will be increasing early prenatal care in underdeveloped, resource-challenged societies to optimize the likelihood of effective screening and treatment.

"Taking screening for congenital syphilis programs to scale will necessitate both a better understanding of the actual interventions that work in a range of settings and contexts, [and] a willingness to address health-financing issues and persuade policy makers of the benefit of eliminating this preventable disease," the authors wrote.

In an accompanying comment, David Mabey, MD, and Rosanna W. Peeling, MD, both of the London School of Hygiene and Tropical Medicine, noted that perhaps the greatest barrier to prevention of fetal death from syphilis is the belief among many in public health and policy that syphilis no longer poses a major risk.

"If you don't test for it, you don't find it, which reinforces the impression that it is no longer an issue," they wrote.

Mabey and Peeling concluded, "This systematic review will remind policy makers that syphilis continues to kill many babies, and will show them how this needless burden of disease can be reduced."

The authors and the editorialists declared that they had no conflicts of interest.

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